28415APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIn.DI G-hLELI KICAL
APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING DIVISION BUILDING PROJF.0'T IDENTIFICATION
PERMITNO.
AO /1 'i C
G o J
4 1
BUILDING ADDRESS`:
SANITARY NO.
D
APPLICAONSUBMITTALUATE
s/
C� y/o /• UNIT# LOT#
O HERS NAME: A EN PI O
I,
CONTRACTOR'S NAME: LIC NO:
NIC
❑
CONTROLp
AR III 'CT/FN'GINFER: LIC NO:
ADDRESS:
CONTACT: HONE:
h5
ySH.QKj6y�8 373o
QTY. ELEC'^IC PERMIT FEE
BUILDING PERMIT INFO
BL G ELEC PLUMB MECH
❑ ❑ ❑
PERMIT ISSUANCE
LICENSEDCONTRACTOR'SDECIARATION
I herby affof Di Nati am licensed and Pr ons icm. Codo,rcommencing with
Seminn7W0) of Division 3m` the sed nderpor Professions Code,)(c mmentiseis in
OR force and effect
APPLIANCES -RESIDENTIAL
I PANELS
JOB DESCRIPTION
License Cluas Lit.#
V UPT02MAMPS
v
Date ARCHITECTS CTS Dr_[CIARATION /
/
I un_ QI _. gya jbp,Hsylpe�ypb �o tly ,� �I
bfiLi��YI%LiC �[
201 - 10011 AMPS
S/Q. FT. F�LOO�R AREA
�R.�f �Yl
.7✓�+
EIS . FT.
I V1
t VVV
OVER 1000 AMPS
SIGNS ELECTRICAL
Livened Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUI HMISC.
I hereby amrm Out I son esern, from the mecum's License law for the
TEMP. METER OR POLE INST,
following reason.(Section7031.5, Business and fee' ions Code Anytityortounty
which requires a pemtit m conawd W¢r, int ve, de alish, or repair any struttme
priormiNissuance,alsorequats Neapplic or such it to file aligned statement
POWER DEVICES
Nat he is licensed pursuant to the provisim . of the Com mots License Lew (Chapter
9(eommencing with Section 7(M0)ofDmsion3oftheBuinesa and NofessiCode)
orthutheisemmpuherefromandnh aaisfomhealleged xemption. Any violation of
I:
ea licannoe civil pe ally of
Section7(UL5byenyapplicaut apermitsubjectsths
SWIMMING POOL ELECTRIC
UATI
VALON �r
Wv,.II
OUfLLTS- SWITCHES - FIXTURES
n t more than five hundred d (8500). ❑ Lasowmcrofflaten y, m unyemployeeswithwaft, s theirsalecomtlo
pernau,
NEW RESIDENTIAL ELECTR _ SQ.PI'.
'STORIES I TYPECONSTRUCTION
will dothework,and the ructure isnot intended oroffcred for ate(See. 7044. Business
and Professions Code: a Connector's License Low, doe o a ply to an owner of
propenywhobuildsori proveathemon,an wh so'mselforthroughhis
ownemployees,provide thutsuchimprovem orator Nmnff<red forWalf.
OCC. GROUP
RES. UNIT'S
L:
however the building ar provemenY sol one ye ofcompletiun, Neowner-
builder will have the bu nofproving a tlidamb d or improve forpurposeof
sale.).
❑ I.asownerofthepro n ivelycont ting with licensed mmmatonto
QTY. PLUMBING PERMIT FEF,
FLOODZONE
APN
answct the project (Sec, ass and N easions Cade) The Conuatmer
License Lawd«snot apply (property hsabuildsorimprovesthereen,and
PERMIT ISSUANCE
whocmarectsfe'such proj swit sea wcto licenscdpursuantomeConvector's se Law.
License
ALTER (EA)sw_
FEE SUMMARY
❑ l om exempt under Sec. , B & P C fm this reason
BACK FLOW PROTECT, DEVICE
SI
T ID. EI:S
SANITARY Y N
RECEIPT#
Owner Dama
WORKMAN NSATION DECLARATION
DRAINS- FLOOR, ROOF, AREA, CONkrCHOOL
TAX Y N
❑ Ihembyafr.m.lhaveacertifcateofconunitoulf-insum.oracenificateof
Waken' Compensation memo. or a certified copy thereof(See3BM. Lab C.)whith
coven allemployttyynyyh rwys.7 Z-�/�
Policy# ,, // 77 JJ
RECEIFrN
FIXTURES - I'M TRAP
PARK FEE Y N
GAS-EA.SYSTEM.IINC.4OUD.LTS
BUILDING DIRECVISION :S
r]
.in any I��,��J.�/1—nA,i3—�fJI�-IS
❑ Ce,h wpyms hcreD, luI. tred.
GAS -EA. SYSTEM-OVER4(EA)
PLANCHECK FEE
GREASUNDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is fled wink she city inspectiondivision.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
OILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200Ff.
ENERGY FEE
(This seeionneed not he complecd ifnhe permit is for one hundreddollms(E Halt
or less.)
WATER HEATER WJVEN OELECTR
IcertifyJJJjjj��Lt in she performance of the work for which thi pertnit is issued,lshdl
not emplo5n in aocr e�q yet -to Ne Worker%
Compensa C oto to es�r s /J
PAID
Date Receiptp
WATER SYSTEM?R[iATING
APPlican'-
NOTICET(YAPPIII A :If, of reeking thisC ifcem of Exemption, you should
REEIDFMIAL PCMB. SQ. FT.
become subject to the Worker's Comperemnion pnm ikima of the Labor Cade, you must
forthwith comply wimhsuch proviaioms or this Permit shall be deemed Invoked.
BUILDING FEF,
SEISMIC FEE.Iherebyeffimm
tF
CONSTRUCTION LENDING AGENCY
that the.is. conawctian lendingagency far the perfarmwceof
the work for which this permit is issued (Sec. 3097. Civ. CJ
ELECTRICFEE
Lenders Name
QTY. MECHANICAL PERMIT FEE
PLUMBING ME
Lcrders Address
I certify that I have mad this application and amte that the above information is
met, l agree m comply with all city and county ordinance, and state lows mlating m
PERMIT ISSUANCE
MECHANICAL FEE
building camwedon, and hereby amhorizarepreamu hives of Chia city m emer.fsm the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECIL
CONSTRUCTION TAX
agree to save, indemnify and keep haranlesa the City of Cupertino aumar,
li ilinies,udgmems,costsondex epees ichmayinanywayaccmeageinsimid City
AIR HANDLING UNIT TO IBM) CFM)
i cons "oo nth rani g this tit.
�7
AIR HANDLING UNIT (OVER 10,00.9CFM)
Signstate ApplicvX. racer Data
EXHAUST HOOD (W/DUCO
pq0 &2
HEATING UNIT (TO 100,100 )
HAZARDOUS MATERIALS DISCLOSURE
Dam xerF #
Will the applicant or future huilding occupant sunter er handle hazardous material
as defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
HEATING UNIT (0 100'"BTU)
C
iv
VENTILA'U FAN(SINGLE RESID)
Code, Section 25532(a)7..g
❑ Yes SI No
iq Q4
fffN
E
-
BOILCOMP (3HPGR 100.000 BTU)
goccupuueym
0applicantmoron,1Will the applimoron,ubvildinmu uipmeordeviceawhich emit
pdous air contaminants res defined by the Bay Area Air Quality Management
ivtricn? )(No
❑ Yee
of the
I have read she hazardous See.materials 5505, 2menta under Chapter understand
Calif "1dm , lth & S. cry Cade, S4ctions 25505, 23537 and 25574. I undenotif Nm
if ebuildin dmsnom curtently se nam. the it is my responsibility to notify the
CI �) u( V V f -L-151 IIVLJ
is
B(ILER-COMP (OVER 100,10(1 BTU)
NEW RESIDENTIAL MECH. SQ. FT,
uP.a of he mqu'remems ich use, F< met p' to iaeuonce o o Ce nificme of
% r
V
ISSUED BY
O ra thorizcd age Date
TOTAL:
OFFICE